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4th. In the treatment of the complications of gastric ulcer, arising from its extension to neighbouring parts, as when perforation has taken place, and the symptoms of peritonitis have been suddenly produced, there is still a slight chance that life may be prolonged; the patient should not be moved, nor anything introduced into the stomach, except a tea-spoonful of water or milk to assuage thirst. Opium must be given freely, as recommended by Dr. Stokes and Dr. Graves, so that the patient may be entirely under its influence, a grain every two or three hours; by this means peristaltic action is checked, the nervous shock diminished, extravasation prevented, adhesions promoted, and life may be thus preserved. For many days aperient remedies should be avoided, and food only taken in the most cautious manner.

If local suppuration have taken place, opium is still the best remedy, in order to diminish irritative fever, to relieve pain, and to place the patient in the most favourable condition for reparative action. If the disease have extended into the chest the prospects of recovery are still less, for sudden acute pleurisy and empyema, or asthenic pneumonia are almost certain to follow. Life may be prolonged by sustaining the patient, and the severity of the symptoms of acute disease of the chest may be partially relieved by ammonia and opium.



THE stomach is one of the organs most frequently affected with cancer; and in this frequency a remarkable contrast is presented when compared with the rarity of strumous disease of the same organ. Every form of cancer is found to occur in the stomach, but instances of medullary and scirrhous cancer are the most numerous, whilst the epithelial, colloid, villous, and melanoid varieties are less constantly observed. It is seen, however, that these varieties pass the one into the other; and thus while one part has almost the firmness and structure of scirrhus, another has the characteristics of medullary growth; and again, the surface also of a medullary cancer may have the appearance of a villous structure. The disease originates in the mucous membrane of the stomach, or its submucous tissue, or it is propagated to the stomach by the affection of the glands in the neighbourhood of the pancreas; and the pylorus, lesser curvature, and cardiac extremity are the parts generally affected. We are not acquainted with the determining cause

of the forms of cancer, or whether the opinion whichi maintained by some pathologists can be established that scirrhus is connected in its origin with the fibrom tissues of the part—medullary with the mucous surfac or gland structure, and colloid especially with the latter—or, whether they are rather indications of the intensity of the morbid action. The part affected has a modifying influence on the character of the disease ; the epithelial cancer of a surface covered by squamous epithelium is different from the same disease, where the epithelium is columnar, an instance of differentiation as applied to morbid changes. It would seem that scirrhous disease is less removed from normal nutritive change than medullary cancer ; in the one there is a greater disposition to form fibroid tissue, in the other the growth is cellular, or nuclear.

During the earlier stages of cancerous disease of the stomach, especially before any growth can be detected on manipulative examination, the symptoms are often exceedingly obscure. It may be convenient to arrange the symptoms into three divisions, according to the respective stages of the disease. The first is the stage of organic dyspepsia before the development of any tumour; the second is that of abnormal growth; and the third, the disintegration of that growth by ulceration or sloughing.

The first symptom often deceptive and obscure; they are those

and with it there is a

peculiarly sallow and anxious expression of countenance; pain at the stomach may be entirely absent, or there may be severe gastrodynia ; pyrosis is frequently present. There is emaciation and general feebleness ; but the tongue may be clean, and the bowels quite regular in action.

In the second stage, a tumour is felt in the region of the stomach, and the symptoms become more distinctive; vomiting is generally a marked sign, especially when the disease is situated at the pylorus or cardia ; and the rejection of food takes place according to the seat of obstruction or irritation of the gastric surface, either a short time or several hours after a meal. In some instances the vomiting so quickly follows deglu: tition as to lead to the supposition of oesophageal disease. The pain also becomes more severe, and is generally of a more lancinating character than that experienced in chronic ulcer of the stomach. The vomited matters are often frothy and fermenting, and present us with abundant sarcina ventriculi. Hæmatemesis is occasionally present. Flatulence distresses the patient, and eructations are frequent; the bowels become constipated; emaciation steadily advances, and the countenance becomes more haggard and cachectic. On careful examination a tumour may generally be felt at the region of the stomach, or of the pylorus; it often increases rapidly, and on account of the wasted condition of the parietes becomes very apparent. The growth is often pulsatile in its character, either from contact with the large abdominal vessels, or from its own excessive vascularity.

In the third stage of the disease, that of disintegration, the symptoms are more severe, and the emaciation is extreme; and the vomiting of coffee-ground substance often precedes a fatal termination. The vomiting sometimes ceases on account of the sloughing of the growth, the obstruction thereby being removed; or the branches of the pneumogastric nerve being destroyed there may be cessation of consequent irritation; the pain also diminishes from similar causes, and as the exhaustion becomes typhoid in its character, it may entirely cease ; but throughout the course of the disease there may be immunity from suffering. Again, it has been shewn by Dr. Kennedy that the size of the tumour may actually lessen from the sloughing process.

The immediate cause of death in gastric cancer differs greatly; the fatal exhaustion may depend, 1st, on the interference with the absorption of nutriment, and with the completion of the digestive process; 2nd, on the sloughing of the growth, and subsequent septic changes in the blood; the patient in such a case becomes rapidly prostrate with typhoid symptoms, the breath is offensive, he is seized with hiccough, and pneumonia of an asthenic kind is induced. 3rd. The fatal termination may ensue from hæmorrhage; when the ulceration produces only slight oozing of blood the

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